Provider Demographics
NPI:1215967260
Name:MADISON RADIOLOGY, PC
Entity type:Organization
Organization Name:MADISON RADIOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BERNARD
Authorized Official - Middle Name:
Authorized Official - Last Name:JAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-245-7351
Mailing Address - Street 1:2 SAMSON ROCK DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:CT
Mailing Address - Zip Code:06443-3005
Mailing Address - Country:US
Mailing Address - Phone:203-245-7351
Mailing Address - Fax:203-245-8838
Practice Address - Street 1:2 SAMSON ROCK DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:CT
Practice Address - Zip Code:06443-3005
Practice Address - Country:US
Practice Address - Phone:203-245-7351
Practice Address - Fax:203-245-8838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT029842085R0202X, 261QR0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, MammographyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD100000221Medicare PIN